HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to ensure the licensed nurses documentation contained information necessary to monitor one of 31 sampled patient's condition (49) receiving a Hemodialysis (a procedure in which impurities or wastes are removed from the blood) treatment. This failure had the potential to result in unmet care needs.

Findings:

During an observation with Registered Nurse (RN) 22, on 2/16/16, at 9:40 AM, in the patient's room, Patient 49 was in bed with the head part slightly elevated at 30 degree angle. He had an oxygen inhalation via nasal cannula. Patient 49 waved his hand when he was asked how he was doing.

During an interview with RN 22, on 2/16/16, at 9:42 AM, she stated Patient 49 was on Hemodialysis three times a week. RN 22 also stated Patient 49 was alert and oriented and he was able to make his needs known.

During a review of the clinical record for Patient 49, the Physician's Order dated 2/16/16, indicated Patient 49 to receive "Hemodialysis STAT ONCE [immediately one time] for 2 hours dry - DX [diagnosis]: Hypoxia [inadequate oxygen tension at the cellular level]." During further review of the clinical record for Patient 49, there was no documentation by the licensed nursing staff for the Hemodialysis treatment ordered on 2/16/16. The Hemodialysis treatment was an additional order by the physician from Patient 49's current order of three times a week (Monday-Wednesday-Friday). It was ordered due to Patient 49's hypoxia.

During an interview with RN 24, on 2/17/16, at 9:15 AM, RN 24 reviewed the licensed nurses documentation and verified there was no information found for the Hemodialysis STAT order. He also stated the licensed staff did not document the reason for the order and Patient 49's response to the treatment.

During an interview with Vice President- Hospital Operations (VP) 2 and RN 24, on 2/17/16, at 9:50 AM, they were made aware of the lack of documentation by the licensed nursing staff for the one time STAT order of Patient 49's Hemodialysis treatment. VP 2 and RN 24 both gave no further information.

The hospital policy and procedure titled "Assessment/Reassessment of Patient" dated 4/16/15, read in part, "...A-3. The goal of the assessment/reassessment process is to provide the patient the best care and treatment possible... 7. All reported changes in patient condition will be documented, as well as the patient response in the medical record..."